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  • Aetna's Policy Clarifications Increase Access to PT Care

    Major commercial insurer Aetna recently provided some clarification on policies related to payment for physical therapy, and it's good news for physical theapists (PTs) and their patients.

    The clarifications help to answer questions related to the company's physical therapy policy, specifically around payment for evaluations and the ways direct access provisions can affect payment. Here's what Aetna said:

    Evaluations could be eligible for payments sooner than the 180-day wait period.
    Although Aetna’s policy reads that "physical therapy evaluations will be eligible for payment once every 180 days," Aetna representatives have informed APTA that evaluations performed within 180 days of the original evaluation may be allowed upon reconsideration or appeal, providing the evaluation is for a new or unrelated condition.

    State direct access provisions could allow for reimbursement from Aetna without a referral.
    Aetna’s policy reads that “Aetna considers physical therapy medically necessary when this care is prescribed by a chiropractor, DO, MD, nurse practitioner, podiatrist or other health professional qualified to prescribe physical therapy according to state law." Representatives from Aetna have clarified that in states with direct access provisions for PTs, a PT is considered an “other health professional qualified to prescribe physical therapy,” meaning that PT services will be reimbursed without an order or referral if all other requirements are met.

    "Aetna has been working with APTA to support access to PT services, and understands the importance of making providers aware of how specific policies are interpreted," said Alice Bell, PT, DPT, an APTA senior payment specialist. "We appreciate Aetna's efforts and look forward to continued cooperation on issues that may impact access to care."

    Comments

    • Aetna has contracted with NIA in several northeast states. NIA is requiring Preauthorization for ALL PT services rendered for Aetna insureds. They are not allowing increased at all with this backwards/ out dated decision.

      Posted by Andrew Mattle on 9/4/2018 7:44 PM

    • Prescription by a chiropractor?? What is being done to correct this nonsense??

      Posted by Blerim Dibra on 9/5/2018 4:07 PM

    • "evaluations performed within 180 days of the original evaluation MAY be allowed upon reconsideration or appeal for a new or unrelated condition." This is nonsense and not good news. Aetna has been a poor payer and required ridiculous paper work for over 20 years. Do not present this as good news or a positive for an insurance company that is no friend of PT.

      Posted by Steve Nellis on 9/6/2018 8:14 AM

    • Aetna won't even allow another PT in my practice to be a provider, citing there isn't enough need however; since they continue to buy up more and more insurance companies, the single Aetna PT in my practice is becoming overwhelmed. What they should have is a site provider agreement like most other insurance companies; that would be good news. Please, stop this nonsense and hold these insurance companies feet to the fire and stop placating them with fluff stories like this when every practitioner dealing with them knows this is BS....and why do I need a referral from a chiropractor to begin with? What a step in the wrong direction.

      Posted by Gregory Waite on 9/10/2018 8:07 AM

    • The new preauthorization system is not conducive to the way PT plan of care is generated. Nor is it compatible with any EMR system that I know of, because they are authorizing "units" of specific codes rather than "visits". What this means, in summary, is that the reimbursement is getting cut via not authorizing enough "units" of each code to correspond to the planned services. NIA actually told me that a PT should take the amount of units allotted, and dole them out accordingly, instead of following the plan of care that was developed. So Utilization Management is trying to dictate treatment, not just approve visits. This goes against post surgical protocol as well as the Plan of Care. Since they are taking 14 days to approve Aetna Medicare Pre Auth, by the time we receive the auth, all or most of the units have already been used. NIA also told me that the Aetna Medicare patients should not schedule during that 2 week lag time between the Eval and the Auth Approval. I have filed a complaint with the PA Insurance Department.

      Posted by Barbara Portena on 10/1/2018 10:58 AM

    • I am having the same exact problem as Barbara Portena. At this point we have put our Aetna members on hold and have requested that they contact Aetna advising them of these issues. I am also in the process of filing a complaint with the NYS Insurance Department. As this is unacceptable. After a call with NIA it was brought to my attention that this is the first Line of Business they are taking on in regards to Therapy. They are primarily a radiology service and their software is aimed towards such. I believe this is why we are having the issue with the "units". I also am waiting to schedule a call with NIA and Aetna as I believe strongly that Aetna needs to be made aware of this issue.

      Posted by Bela Gomes on 12/6/2018 2:17 PM

    • The Aetna/ NIA authorization process just became effective in NJ in January of 2019. In a way I am glad that others are having the same problems with the company that I am. I am not alone in dislike of them, it seems. Originally we were told by Aetna that only Medicare patients would need the authorization. Then we began to get claim denials for some of our other patients. It turned out that Aetna requires auth for all fully funded plans as well and never informed us. NIA's original problem was not authorizing enough units to allow us to treat the patient accordingly but, with an explanation of why they were needed, a request for additional units was usually granted. They also backdated our auth request when we explained that Aetna never told us auth was needed for our patients with fully funded plans. However, Aetna and NIA do not communicate these authorizations very well. When I called Aetna to inform them authorization was received I was told they could not see the NIA system and that we had to manually fax over the authorizations we received. As anyone who has received an NIA auth knows, they are very long and confusing with additional units, changed dates, etc. As of writing this we are still waiting on payment for these dates of service from the beginning of January. Our new problem with NIA is a habit of them requesting exorbitant amounts of units (which are not even for codes that Aetna will cover) and then partially approving them. They send a denial for the ones that were not approved and when we send for additional visits our requests are seen as appeals not requests for additional visits. I have spoken to several people at NIA about this problem as we cannot request numbers of units or codes, they are arbitrarily assigned by NIA. I have also suggested a solution for it ( if they want to auth units let the PT request them ala an attending provider treatment form such as is used for motor vehicle insurance) and have been told that that would be a good idea but nothing has been done and I doubt it will be. It seems Aetna chose a company ill equipped to authorize physical therapy and is doing nothing to correct it. The one thing in NIA's favor right now is that their employees are helpful and courteous and seem to be in the US. I can't even begin to describe what more of a nightmare it would be to call someone everyday (because I make at least one call to NIA a day about something that is incorrect) and have them be nasty or not understand what I am saying. It is sad because the patients are the ones to suffer for all of this but then to chose a company like NIA without researching how they would communicate with them or how their authorization system would work, Aetna must not care about patients just profit.

      Posted by Laura Tully on 2/21/2019 11:34 AM

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